Gov. Gavin Newsom has called President Trump’s two-year barrage to undermine the Affordable Care Act “vandalism,” while other state and national health care experts have described it as “sabotage,” a “slow bleed,” or even “death by a thousand cuts.”

Local and state health officials, and now the newly sworn-in California governor, have sought to blunt the continuing onslaught from Trump and congressional Republicans to repeal or undermine the nation’s health care law.

Sonoma County health care leaders say the stakes are in the millions of dollars for hospitals and community clinics that have benefited from the law since it was fully implemented in 2014.

Unless more steps are taken to protect the Affordable Care Act, area medical providers say they could begin to see an increasing number of uninsured patients and multimillion dollar annual losses because of unpaid patient medical bills and charity care.

“It’s a game of whack-a-mole; we’re trying to make the law work in California, but every time we turn around there’s another attack by the federal government,” said Anthony Wright, executive director of Health Access, a statewide health consumer advocacy group.

Wright and others say the effects of President Trump’s repeated attempts to derail his predecessor’s signature health care law largely have been deflected in California. There are some local signs, though, the law may be starting to weaken.

According to Covered California, the state’s health insurance exchange, the number of new enrollees statewide has declined slightly, even as the tally of people renewing their medical coverage plans through Covered California has remained high. That may change, however, because the agency said late last week it was still processing last-minute enrollees who had until Friday to complete application forms.

“We are seeing strong renewal numbers, but we’re seeing a slight decrease in the number of new consumers signing up,” said James Scullary, a Covered California spokesman.

Scullary said any drop in enrollment could affect the “risk pool,” especially if those who are opting out are younger people. “If it’s determined that primarily healthy people left, that could have an impact on premiums,” he said.

Another sign the health care law could be weakening is a recent drop in the number of people who are enrolled in Medi-Cal, the state’s version of the federal Medicaid program to expand coverage for low-income people and those with disabilities. Aside from creating federal health exchanges and allowing states such as California to create their own, the statute greatly expanded Medicaid to low-income residents who were previously ineligible.

The president’s actions against the Affordable Care Act include: the creation of short-term, low-cost individual health plans critics say would destabilize the law; the elimination of the individual mandate, making it easier for people to avoid the federal tax penalty for going without health insurance; and ending federal cost-sharing reduction payments to insurance companies who offer affordable plans to low-income Americans.

In response, last year the California Legislature banned short-term, low-cost health plans. And Gov. Newsom has proposed a sweeping health care plan that would create a statewide individual mandate and expand coverage to undocumented immigrants who were left out of the Affordable Care Act.

In December, a Texas judge cited the elimination of the individual mandate in his decision to render the entire Affordable Care Act unconstitutional. The law still stands while the decision is being appealed to a higher court.

Since the beginning of the Trump presidency, there’s been a 7.5 percent decline in Medi-Cal membership in Sonoma County between 2017 and 2019, according to Partnership HealthPlan of California, the nonprofit health care organization that administers Medi-Cal in Sonoma County and 13 other Northern California counties. Membership in Sonoma County peaked at about 114,000 in July 2017 and has since slowly declined, said Dustin Lyda, a spokesman for Partnership HealthPlan.

Partnership HealthPlan has seen a 4.3 percent decline in overall membership, he said. The exact cause is unclear at this point, since Partnership does not receive information about why people are not enrolling in Medi-Cal, he said.

In October, the Trump administration proposed making participation in Medicaid a “public charge,” which could be a negative factor in determining an immigrant’s admission to the country as a legal resident. Partnership HealthPlan said many of the health centers it partners with have reported some of their patients now fear enrollment in Medi-Cal because it may jeopardize their application for legal residency.

Naomi Fuchs, CEO of Santa Rosa Community Health, the largest network of health centers in Sonoma County, echoed that concern. Fuchs said it’s possible because of the volatile political environment around immigration and the president’s proposed “public charge” rule some immigrants may not be enrolling their children for Medi-Cal benefits, even though the children are U.S. citizens.

Fuchs said her health centers have seen a decline of about 3,000 patients since 2017, when they had a total of 45,000 patients. But she said some of that decrease likely was caused by the 2017 wildfires.

“In that first six months after the fire, people were being moved around a lot — our systems were not in good shape,” she said.

Fuchs said it’s also possible with the local economy improving and low unemployment, some people may have found better paying jobs that now make them ineligible for Medi-Cal. It’s unclear, though, if those jobs offer good health care.

“Without health insurance, these families may opt to go without needed care or turn to high-cost emergency rooms to receive treatment,” she said. “We’ve seen an increase in our percentage of uninsured. More people are coming to us as uninsured.”

Santa Rosa Community Health centers now provides more than 32,500 medical visits a year to people who are uninsured.

After the full implementation of the national health care law in 2014, Santa Rosa Memorial Hospital and Sutter Santa Rosa Regional Hospital both saw declines in their uncompensated care costs. That includes the cost of charity care and bad patient debt, which for the most part comes from unpaid medical bills.

For example, Memorial Hospital’s cost of charity care and bad debt went from nearly $10 million in 2014 to $5.7 million in 2017, according to the latest data available from California’s Office of Statewide Health Planning and Development. Bad debt alone has gone from $4.4 million to $1.2 million during that period.

Sutter Santa Rosa Regional Hospital also saw a significant decline in uncompensated care in 2015, from $7.8 million in 2014 to $3.8 million the next year. But the hospital, has since seen steady increases to its charity care and patient medical bills that go unpaid. Bad debt dropped to $1.1 million in 2015, from $3.9 million the year before, before increasing again to $1.7 million in 2017.

Michael Tou, executive director of government and public affairs for Providence St. Joseph Health, which owns and operates Memorial Hospital, said keeping people insured — whether it’s through Medi-Cal or the state’s health exchange program — helps keep health care costs down.

“It’s a very costly endeavor to get treated in an emergency department,” he said.

Tou said Providence St. Joseph Health and other local hospitals are supporting efforts to appeal the recent federal court ruling in Texas that declared the health care law unconstitutional, as well as state efforts to bolster medical coverage under the law.

Fuchs said these steps and more should keep the law in tact, despite federal attacks.

“The Affordable Care Act is still very strong, and it’s going to remain strong. I really feel confident about that,” Fuchs said. “These are just little flesh wounds, they’re just little bumps in the road.”

You can reach Staff Writer Martin Espinoza at 707-521-5213 or martin.espinoza@pressdemocrat.com.